breech presentation, shoulder dys. etc

1. MALPRESENTATION
And CORD PROLAPSE

2. MALPRESENTATION
Malpresentation is the situation
where a fetus within the uterus is in
any position that is not cephalic

7. ETIOLOGIC FACTORS -
 Maternal
Great parity
Pelvic tumors
Pelvic contracture
Uterine malformation
 Fetal
Prematurity
Multiple gestation
Hydramnios
Macrosomia
Hydrocephaly
Trisomies
Anencephaly
Myotonic dystrophy
Placenta previa

8. BREECH PRESENTATION

9. Introduction
Breech presentation occurs in 3-4% of all deliveries. The
occurrence of breech presentation decreases with advancing
gestational age. Breech presentation occurs in 25% of births
that occur before 28 weeks’ gestation, in 7% of births that
occur at 32 weeks, and 1-3% of births that occur at term.
.
Perinatal mortality is increased 2- to 4-fold with breech
presentation, regardless of the mode of delivery. Deaths most
often are associated with malformations, prematurity, and
intrauterine fetal demise.

10. PREDISPOSING FACTORS
 prematurity, uterine abnormalities (eg, malformations,
fibroids), fetal abnormalities (eg, CNS malformations, neck
masses, aneuploidy), and multiple gestations.
AF abnormality.Abnormal placentation.
Contracted pelvis.MG.Pelvic tumor.
 Perinatal mortality is increased 2- to 4-fold with breech
presentation, regardless of the mode of delivery.
 Congenital malformation 6%

11. TYPES OF BREECHES
 Frank breech (50-70%) - Hips flexed,
knees extended
 Complete breech (5-10%) - Hips flexed,
knees flexed
 Footling or incomplete (10-30%) - One
or both hips extended, foot presenting

15. POSITION
SA,SP,LST,RST
LSP,RSP.LSA,RSA

18. STATION

19. DIAGNOSIS
Palpations and
ballottement
Pelvic exam
X-ray studies
Ultrasound

20. MANAGEMENT
Antepartum
During labor
Delivery

22. Criteria for VD or CS
VD
Frank
GA>34w
FW=2000-3500gr
Adequate pelvis
Flexed head
Nonviable fetus
No indication
Good progress labor
CS
FW<1500or> 3500gr
Footling
Small pelvis
Deflexed head
Arrest of labor
GA24-34w
Elderly PG
Inf or poor history
Fetal distress

23. VAGINAL BREECH DELIVERY
 Three types of vaginal breech deliveries:
1. Spontaneous breech delivery
2. Assisted breech delivery
3. Total breech extraction

24. Once the feet have delivered, there
may be temptation to pull on the feet.
However, this should never be done
with a singleton gestation because it
may precipitate an entrapped head in
an incompletely dilated cervix or it
may precipitate nuchal arms. As long
as the fetal heart rate is stable and no
physical evidence of a prolapsed cord
exists, expectant management may be
followed, awaiting full cervical
dilatation.
.
Footling breech presentation-

25. Assisted vaginal breech delivery
 Thick meconium passage
is common as the breech
is squeezed through the
birth canal. This usually is
not associated with
meconium aspiration
because the meconium
passes out of the vagina
and does not mix with the
amniotic fluid.

26.  Picture 3. Assisted vaginal
breech delivery: The
Ritgen maneuver is
applied to take pressure
off the perineum during
vaginal delivery.
Episiotomies often are cut
for assisted vaginal
breech deliveries, even in
multiparous women, to
prevent soft-tissue
dystocia.

27.  Picture 4. Assisted vaginal breech delivery: No
downward or outward traction is applied to the fetus
until the umbilicus has been reached.

28. Picture 5. Assisted vaginal breech delivery: With a
towel wrapped around the fetal hips, gentle
downward and outward traction is applied in
conjunction with maternal expulsive efforts until the
scapula is reached. An assistant should be applying
gentle fundal pressure to keep the fetal head flexed.

29. Picture 6. Assisted vaginal breech delivery: After
the scapula is reached, the fetus should be rotated
90° in order to delivery the anterior arm.

30. Picture 7. Assisted vaginal breech delivery: The anterior
arm is followed to the elbow, and the arm is swept out of
the vagina.

31. Picture 8. Assisted vaginal breech delivery: The fetus is
rotated 180°, and the contralateral arm is delivered in a
similar manner as the first. The infant is then rotated 90°
to the back-up position in preparation for delivery of the
head.

32. Picture 9. Assisted vaginal breech delivery: The fetal head is
maintained in a flexed position by using the Mauriceau-Smellie-
Veit maneuver, which is performed by placing the index and
middle fingers over the maxillary prominence on either side of
the nose. The fetal body is supported in a neutral position with
care to not overextend the neck.

33. Picture 10. Piper forceps application: Pipers are
specialized forceps used only for the aftercoming head of
a breech presentation. They are used to keep the head
flexed during extraction of the fetal head. An assistant is
needed to hold the infant while the operator gets on one
knee to apply the forceps from below.

34. Picture 11. Assisted vaginal breech delivery: Low 1-minute Apgar scores are not
uncommon after a vaginal breech delivery. A pediatrician should be present for the
delivery in the event that neonatal resuscitation is needed.

35. Picture 12. Assisted vaginal
breech delivery - The neonate
after birth

36. Risks
Lower Apgar scors
An entrapped head
Nuchal arms
Cervical spine injury
Cord prolapse
,

37. PROGNOSIS

38. Table 1. Zatuchni-Andros Breech Scoring
Add 0 Points Add 1 Point Add 2 Points
Parity 0 1 2
Gestational age
(wk)
39+ 38 <37
EFW (lb) 8 7-8 <7
Previous breech 0 1 2
Dilatation 2 3 4
Station -3 -2 -1
If the score is 0-4, cesarean delivery is recommended

39. VERSION
External
Internal

43. Internal podalic version

44. COMPOUND PRESENTATION

45. COMPLICATION SD
Immediate neonatal;birth
asphyxia ,traumatic injury
Maternal;PPH,lacerations

46. SHOULDER
DYSTOCIA (Sh.D)

47. Shoulder dystocia will
still the obstetric
nightmare

48. Definition:
Shoulder dystocia (Sh. D) is the inability to
deliver the fetal shoulders after delivery of
the head, without the aid of specific
maneuvers (ie. other than gentle downward
traction on the head) .

49. Definition
Objective definition :
Mean head-to-body
delivery time > 60 seconds

50. PATHOPHYSIOLOGY
Shoulder dystocia results from
a size discrepancy between the
fetal shoulders and the pelvic inlet
when:
1. The bisacromial diameter is large
relative to the biparietal diameter
2. Pelvic brim is flat rather
than gynecoid
.

51. SHOULDER DYSTOCIA
0.15-1.7%,
Risk
factor;macrosomia,diabetes,history
of SD,prolonged2th stage of
labor,maternal
obesity,multiparity,postterm.
50%SDnorisk factor
Sono

53. Release techniques
1. Maternal
2. Fetal
Complications of Sh D

54. 1. Postpartum hemorrhage 11%
2. Vaginal laceration 19%
3. Perineal tears 2nd&3rd 4%
4. Cervical laceration 2%
Maternal Complications (25%)

55. Release techniquesFetal Complications of Sh D

56. Brachial plexus injuries,
Fractures of the humerus, and
Fractures of the clavicle
are the most commonly reported
injuries associated with shoulder
dystocia
Fetal Complications of Sh D

57. Traction combined with fundal
pressure has been associated with a
high rate of brachial plexus injuries
and fractures
Fetal Complications of Sh D

58. Fewer than 10% of deliveries complicated by
shoulder dystocia will result in brachial plexus
injury.
Fetal Complications of Sh D

59. Release techniques
Head –shoulder interval > 7min.
Brain injury
With hypoxic fetus it is much shorter
Fetal Complications
(sensitivity & specificity :70 %)

60. Can shoulder
dystocia be
predicted?

61. RISK FACTORS FOR SHOULDER DYSTOCIA
PRECONCEPTIONAL:
1. Maternal birth weight
2. Prior shoulder dystocia 12%
3. Prior macrosomia
4. Pre-existing diabetes
5. Obesity
6. Multiparity
7. Prior gestational diabetes
8. Advanced maternal age

62. RISK FACTORS FOR SHOULDER
DYSTOCIA
Antenatal:
 Excessive maternal weight gain
 Macrosomia
 G. diabetes
 Short stature
 Post term

63. RISK FACTORS FOR SHOULDER
DYSTOCIA
Intrapartum:
1. Protracted or arrested active phase
2. Protracted or failure of descent of
head
3. Need for midpelvic assisted delivery

64. MANAGEMENT
.
(Within5- 7 minutes)

65. Management
1-Suprapubic pressure
2-McRobert manoeuver
3- Woods corkscrew .
4-Rubens manoeuver
5-Delivery of P. shoulder
6-Zavanelli
7-All fours
8-Cleidotomy
9-symphysiotomy

66. ACOG Issues Guidelines
Recommendation 1991
1-Call for help: assistants, anesthesiologist
2-Initial gentle attempt of traction.
3-Generous episiotomy.
4-Suprapubic pressure.

67. ACOG Issues Guidelines
Recommendation 1991
.
5-The Mc Roberts
manoeuvre
(Exaggerated hyper
flexion of the thighs
upon the abdomen.)
& Suprapubic
pressure in the
direction of the Foetal
face

68. No increase in pelvic dimensions.
Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder
Gherman et al Obstet Gynecol 95:43 ,2000
McRoberts manoeuvre: X ray pelvimetry study

69. ACOG Issues Guidelines
Recommendation 1991
.
If Mc Roberts failed:
6-Woods manoeuvre:
•The hand is placed
behind the posterior
shoulder of the fetus.
•The shoulder is
rotated progressively 180 d in a corkscrew manner so
that the impacted anterior shoulder is released.

70. ACOG Issues Guidelines
Recommendation 1991
.
7-Delivery of the
posterior arm :

71. By inserting a hand
into the posterior
vagina and ventrally
rotating the arm at
the shoulder
delivery
over the
perineum

74. UMBILICAL CORD
PROLAPSE

75. Umbilical Cord Prolapse
 Etiology
– 1-275 deliveries
 Classification
– Complete: cord is seen or palpated ahead of presenting part
(OB Emergency)
– Fundic: cord felt through intact membranes ahead of
presenting part
– Occult: hidden or not visible at any time during course of
labor
 Definition: umbilical cord that lies below/beside
presenting part

76. Umbilical Cord Prolapse
 Precipitating factors:
 Long umbilical cord
 Abnormal location on
placenta
 Small or preterm infant
 Polyhydramnios
 Multiple gestation
 Precipitating factors:
 Amniotomy before fetal
head is engaged
 IUPC placement
 External cephalic
version

77. Clinical Manifestations:
 Cord observed or palpated
 Bradycardia following ROM
 Repetitive, variable decelerations that do not
respond to medical intervention (e.g. amnioinfusion)
 Prolonged decelerations (>15 bpm lasting 2 mins or
longer yet <10 mins)

78. Nursing interventions:
 Assess fetal viability
 Call for assistance
 Relieve pressure from cord (usually presenting part)
 Continuous manual relief of pressure from presenting part
 Avoid excessive manipulation of cord
 Re-position client: Trendelenburg, modified Sim’s, or knee-chest
 Prepare for emergency delivery
 Administer oxygen by mask 10-12 L/min
 Fill maternal bladder with 500-700 cc NS
 Continuous fetal monitoring
 Possible neonatal resuscitation (notify neonatal team per
hospital protocol)

79. Aim of Medical management:
 Immediate delivery of viable infant
 Hallmark treatment: C-section